Original Article
Predictors of Percutaneous Endoscopic Gastrostomy Tube Placement in Patients With Severe Dysphagia From an Acute-Subacute Hemispheric Infarction

https://doi.org/10.1016/j.jstrokecerebrovasdis.2010.05.010Get rights and content

This study investigated the influence of age, National Institutes of Health Stroke Scale (NIHSS) score, time from stroke onset, infarct location and volume in predicting placement of a percutaneous endoscopic gastrostomy (PEG) tube in patients with severe dysphagia from an acute-subacute hemispheric infarction. We performed a retrospective analysis of a hospital-based patient cohort to analyze the effect of the aforementioned variables on the decision of whether or not to place a PEG tube. Consecutive patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes for acute ischemic stroke, Current Procedural Terminology (CPT)-4 codes for a formal swallowing evaluation by a speech pathologist, and procedure codes for PEG placement over a 5-year period from existing medical records at our institution. Only patients with severe dysphagia were enrolled. A total of 77 patients met inclusion criteria; 20 of them underwent PEG placement. The relationship between age (dichotomized; < and ≥75 years), time from stroke onset (days), NIHSS score, acute infarct lesion volume (dichotomized; < and ≥100 cc), and infarct location (ie, insula, anterior insula, periventricular white matter, inferior frontal gyrus, motor cortex, or bilateral hemispheres) with PEG tube placement were analyzed using logistic regression analysis. In univariate analysis, NIHSS score (P = .005), lesion volume (P = .022), and presence of bihemispheric infarction (P = .005) were found to be the main predictors of interest. After multivariate adjustment, only NIHSS score (odds ratio [OR], 1.15; 90% confidence interval [CI], 1.02-1.29; P = .04) and presence of bihemispheric infarcts (OR, 4.67; 90% CI, 1.58-13.75; P = .018) remained significant. Our data indicates that baseline NIHSS score and the presence of bihemispheric infarcts predict PEG placement during hospitalization from an acute-subacute hemispheric infarction in patients with severe dysphagia. These results require further validation in future studies.

Section snippets

Patients and Methods

All patients were identified retrospectively using International Classification of Diseases, Ninth Revision (ICD-9) codes for stroke (433, 43311, 43321, 43331, 43411), Current Procedure Terminology (CPT)-4 codes for swallowing assessment by a speech pathologist (92610, 92611, 74230) and procedure codes for PEG placement (430, 431,432) over a 5-year period from April 1, 2003, to March 31, 2008, from the inpatient population at our hospital. Ischemic stroke patients who underwent formal

Results

The baseline characteristics of our study cohort are tabulated in Table 1. Most of our patients had a partial anterior circulation stroke, were elderly (median age, 76 years) and female, and had sustained a moderately severe stroke with a relatively large infarct volume. The time from stroke onset to swallowing evaluation is presented in Table 2. Three patients in the PEG group and 4 patients in the no-PEG group had an abbreviated initial bedside swallowing evaluation because of drowsiness;

Discussion

The main results of this study demonstrate that initial stroke severity as assessed by NIHSS score and the presence of bihemispheric infarcts are significantly associated with the decision to place a PEG tube in a patient with severe dysphagia due to acute or subacute hemispheric infarction, after controlling and correcting for the possible confounding effects of age, lesion location and time from stroke onset to initial swallowing evaluation. PEG placement also showed a trend toward higher

Acknowledgment

S.K. receives partial salary support from the National Institutes of Health (NIH) (Grant NINDS 5UO1-NS044876-03) and receives research support from the Charles and Irene Goldman Neurology Research Fund. M.S. receives research support from the NIH (Grant NINDS 1R01-NS057127-01A1, NINDS 1R01-NS045754-01A2, and 5R01-HL46690-14). G.S. receives research support from the NIH (Grants NINDS 1R01-NS045049, NIDCD 1RO1-DC008796, NIDCD 3R01-DC008796-02S1, R01-DC009823-01, and 1R01-NS057127). S.L. receives

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